#357: Surgical Site Infection (SSI)

Quality ID

357

High Priority Measure

Yes

Specifications

Registry

Measure Type

Outcome

Specialty

General Surgery Otolaryngology Plastic Surgery Vascular Surgery

Measure description

Percentage of patients aged 18 years and older who had a surgical site infection (SSI)

 

Instructions

This measure is to be submitted each time a procedure for a surgical site infection is performed during the performance period ending November 30th. There is no diagnosis associated with this measure. This measure may be submitted by eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.

Measure Submission:

The listed denominator criteria is used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions allowed by the measure. The quality-data codes listed do not need to be submitted for registry submissions; however, these codes may be submitted for those registries that utilize claims data.

 

Denominator

Patients aged 18 years and older who have undergone a surgical procedure

Denominator Criteria (Eligible Cases):

All patients aged 18 years and older

AND

Patient procedure during the performance period (CPT): 11004, 11005, 11006, 11450, 11451, 11462, 11463, 11470, 11471, 11770, 11771, 11772, 15920, 15931, 15933, 15940, 15950, 19101, 19110, 19112, 19120, 19125, 19300, 19301, 19302, 19303, 19304, 19305, 19306, 19307, 20100, 20101, 20102, 20200, 20205, 21552, 21554, 21555, 21556, 21931, 21932, 21933, 22900, 22901, 22902, 22903, 22904, 22905, 23071, 23073, 23075, 24071, 24073, 24075, 25071, 27043, 27047, 27327, 27337, 36561, 36563, 36566, 36590, 36818, 36819, 36820, 36821, 36825, 36830, 38100, 38115, 38120, 38308, 38500, 38525, 38530, 38550, 38555, 38740, 38745, 38760, 38765, 39540, 39541, 43122, 43279, 43280, 43281, 43282, 43325, 43327, 43330, 43332, 43333, 43336, 43337, 43340, 43361, 43500, 43501, 43502, 43510, 43520, 43605, 43610, 43611, 43620, 43621, 43622, 43631, 43632, 43633, 43634, 43640, 43641, 43644, 43645, 43651, 43652, 43653, 43770, 43771, 43772, 43773, 43774, 43775, 43800, 43810, 43820, 43825, 43830, 43831, 43832, 43840, 43843, 43845, 43846, 43847, 43848, 43850, 43855, 43860, 43865, 43870, 43880, 43886, 43887, 43888, 44005, 44010, 44020, 44021, 44025, 44050, 44055, 44110, 44111, 44120, 44125, 44126, 44127, 44130, 44140, 44141, 44143, 44144, 44145, 44146, 44147, 44150, 44151, 44155, 44156, 44157, 44158, 44160, 44180, 44186, 44187, 44188, 44202, 44204, 44205, 44206, 44207, 44208, 44210, 44211, 44212, 44227, 44300, 44310, 44312, 44314, 44316, 44320, 44322, 44340, 44345, 44346, 44602, 44603, 44604, 44605, 44615, 44620, 44625, 44626, 44640, 44650, 44660, 44661, 44680, 44700, 44800, 44820, 44850, 44900, 44950, 44960, 44970, 45000, 45005, 45020, 45100, 45108, 45110, 45111, 45112, 45113, 45114, 45116, 45119, 45120, 45121, 45123, 45126, 45130, 45135, 45136, 45150, 45160, 45171, 45172, 45505, 45540, 45541, 45550, 45562, 45563, 45800, 45805, 45900, 45905, 46040, 46045, 46060, 46080, 46250, 46255, 46257, 46258, 46260, 46261, 46262, 46270, 46275, 46280, 46285, 46288, 47010, 47015, 47100, 47120, 47122, 47125, 47130, 47300, 47350, 47360, 47361, 47362, 47370, 47371, 47380, 47400, 47420, 47425, 47460, 47480, 47562, 47563, 47564, 47570, 47600, 47605, 47610, 47612, 47620, 47711, 47712, 47715, 47720, 47721, 47740, 47741, 47760, 47765, 47780, 47785, 47800, 47900, 48000, 48001, 48020, 48100, 48105, 48120, 48140, 48145, 48146, 48148, 48150, 48152, 48153, 48154, 48155, 48500, 48510, 48520, 48540, 48545, 48547, 48548, 49000, 49002, 49010, 49020, 49040, 49060, 49062, 49203, 49204, 49205, 49255, 49320, 49321, 49322, 49323, 49324, 49325, 49402, 49421, 49422, 49425, 49426, 49429, 49436, 49505, 49507, 49520, 49521, 49525, 49540, 49550, 49553, 49555, 49557, 49560, 49561, 49565, 49566, 49570, 49572, 49585, 49587, 49590, 49650, 49651, 49652, 49653, 49654, 49655, 49656, 49657, 49900, 50205, 50500, 50740, 55520, 55540, 57305, 57307, 60200, 60210, 60212, 60220, 60225, 60240, 60252, 60254, 60260, 60270, 60271, 60500, 60502, 60520, 60540, 60545, 60650

 

Numerator

Number of patients with a surgical site infection

Numerator Instructions:

INVERSE MEASURE - A lower calculated performance rate for this measure indicates better clinical care or control. The “Performance Not Met” numerator option for this measure is the representation of the better clinical quality or control. Submitting that numerator option will produce a performance rate that trends closer to 0%, as quality increases. For inverse measures, a rate of 100% means all of the denominator eligible patients did not receive the appropriate care or were not in proper control.

Definitions:

Superficial Incisional SSI - Superficial incisional SSI is an infection that occurs within 30 days after the operation and infection involves only skin or subcutaneous tissue of the incision and at least one of the following:

  • Purulent drainage, with or without laboratory confirmation, from the superficial incision
  • Organisms isolated from an aseptically obtained culture of fluid or tissue from the superficial incision
  • At least one of the following signs or symptoms of infection: pain or tenderness, localized swelling, redness, or heat AND superficial incision is deliberately opened by the surgeon, unless incision is culture-negative
  • Diagnosis of superficial incisional SSI by the surgeon or attending physician

Deep Incisional SSI - Deep Incision SSI is an infection that occurs within 30 days after the operation and the infection appears to be related to the operation and infection involved deep soft tissues (for example, fascial and muscle layers) of the incision and at least one of the following:

  • Purulent drainage from the deep incision but not from the organ/space component of the surgical site
  • A deep incision spontaneously dehisces or is deliberately opened by a surgeon when the patient has at least one of the following signs or symptoms: fever (> 38 C), localized pain, or tenderness, unless site is culture-negative
  • An abscess or other evidence of infection involving the deep incision is found on direct examination, during re-operation, or by histopathologic or radiologic examination
  • Diagnosis of a deep incision SSI by a surgeon or attending physician

Organ/Space SSI - Organ/Space SSI is an infection that occurs within 30 days after the operation and the infection appears to be related to the operation and the infection involves any part of the anatomy (for example, organs or spaces), other than the incision, which was opened or manipulated during an operation and at least one of the following:

  • Purulent drainage from a drain that is placed through a stab wound into the organ/space.
  • Organisms isolated from an aseptically obtained culture of fluid or tissue in the organ/space
  • An abscess or other evidence of infection involving the organ/space that is found on direct examination, during re-operation, or by histopathologic or radiologic examination
  • Diagnosis of an organ/space SSI by a surgeon or attending physician

Numerator Options:

Performance Met: Surgical site infection (G9312)

OR

Performance Not Met: No surgical site infection (G9311)

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